And must meet at least one of the following:
The patient has current signs and/or symptoms (i.e., the test is being used for diagnostic purposes).
Conventional diagnostic procedures are inconclusive.
The patient has risk factors or a particular family history that indicate a genetic cause.
The patient meets defined criteria that place them at high genetic risk for the condition.
Generally, genetic testing is not covered for:
Population screening without a personal or family history, with the exception of preconception or prenatal carrier screening for certain conditions, such as cystic fibrosis, Tay-Sachs disease, sickle cell disease, and other hemoglobinopathies
Informational purposes alone (i.e., testing of minors for adult-onset conditions, and self-referrals or home testing)
Test is considered Experimental or Investigational.
26. Hearing Services include:
Exams, tests, services and supplies to diagnose and treat a medical condition.
Implantable hearing devices.
27. Home Health Care Services: (Refer to Home Health Care section of this SPD).
28. Hospice Care Services: Treatment given at a Hospice Care Facility must be in place of a stay in a Hospital or Extended Care Facility, and can include:
Assessment includes an assessment of the medical and social needs of the Terminally Ill person, and a description of the care to meet those needs.
Inpatient Care in a facility when needed for pain control and other acute and chronic symptom management, psychological and dietary counseling, physical or occupational therapy and part-time Home Health Care services.
Outpatient Care provides or arranges for other services as related to the Terminal Illness which include the services of a Physician or Qualified physical or occupational therapist, or nutrition counseling services provided by or under the supervision of a Qualified dietician.
The Covered Person must be Terminally Ill with an anticipated life expectancy of about six months.
Services, however, are not limited to a maximum of six months if continued Hospice Care is deemed appropriate by the Physician, up to the maximum hospice benefits available under the Plan.
29. Hospital Services (Includes Inpatient Services, Surgical Centers And Inpatient Birthing Centers). The following benefits are covered:
Semi-private room and board. For network charges, this rate is based on network re-pricing.
For non-network charges, any charge over a semi-private room charge will be a Covered Expense only if determined by the Plan to be Medically Necessary. If the Hospital has no
31. Indemnity Benefit for Adoption shall be available to the Covered Person when all of the following conditions are met:
The Covered Person’s Plan provides maternity benefits for the Covered Person or the Covered Person’s spouse and coverage is in effect on the date a newborn Child is placed for the
purpose of adoption.
A newborn Child is placed for the purpose of adoption with the Covered Person within one year after the Child’s birth and the date of placement is on or after the Covered Person’s effective date.
The Covered Person submits a written request for the Indemnity Benefit for Adoption along with proof of placement of adoption. Proof of placement shall be a copy of the court order (or its equivalent) showing the date of placement for adoption. The written request must contain the Child’s name, date of birth, and a statement regarding any other health coverage of the adoptive parent(s). The written request shall be addressed to the claims administrator at the following address:
UMR
PO Box 8033
Wausau, WI 54402-8033
In the event of adoption of more than one newborn Child (for example, twins), the Indemnity Benefit for Adoption applies for each Child adopted.
In the event the Covered Person and/or the Covered Person’s spouse is covered by more than one health benefit plan, the Indemnity Benefit for Adoption shall be prorated between or among the Plans so that the full amount provided by both or all of the Plans does not exceed the amount shown in the Schedule of Benefits of this SPD.
In the event the Plan excludes care and treatment of pregnancy, the Indemnity Benefit for Adoption is not available to that Covered Person or that Covered Person’s spouse.
In the event the post-placement evaluation disapproves the adoption placement and a court rules the adoption may not be finalized because of an act or omission of an adoptive parent or parents that affects the Child’s health or safety, the Covered Person shall be liable for
repayment of the Indemnity Benefit for Adoption. The full amount of such benefit shall be refunded by the Covered Person to the Claims Administrator within 30 days after that date the Child is removed from placement.
32. Infant Formula administered through a tube as the sole source of nutrition for the Covered Person.
33. Infertility Treatment to the extent required to treat or correct underlying causes of infertility, when such treatment is Medically Necessary and cures the condition, alleviates the symptoms, slows the harm, or maintains the current health status of the Covered Person.
Infertility Treatment does not include Genetic Testing. (See General Exclusions for details).
34. Laboratory or Pathology Tests and Interpretation Charges for covered benefits.
35. Manipulations: Treatments for musculoskeletal conditions when Medically Necessary. Also refer to Maintenance Therapy under the General Exclusions section of this SPD.
36. Massage Therapy. (See Therapy Services below) 37. Maternity Benefits for Covered Persons include:
Hospital or Birthing Center room and board.
Vaginal delivery or Cesarean section.
Non-routine prenatal care.
Postnatal care.
Medically Necessary diagnostic testing.
Abdominal operation for intrauterine pregnancy or miscarriage.
Outpatient Birthing Centers.
Midwives.
38. Mental Health Treatment (Refer to Mental Health section of this SPD).
39. Modifiers or Reducing Modifiers if Medically Necessary, apply to services and procedures performed on the same day and may be applied to surgical, radiology and other diagnostic procedures. For providers participating with a primary or secondary network, claims will be paid according to the network contract. For providers who are not participating with a network, where no discount is applied, the industry guidelines are to allow the full Usual and Customary fee allowance for the primary procedure and a percentage (%) of the Usual and Customary fee allowance for all secondary procedures. These allowances are then processed according to Plan provisions. A global package includes the services that are a necessary part of the procedure. For individual services that are part of a global package, it is customary for the individual services not to be billed separately. A separate charge will not be allowed under the Plan.
40. Nursery And Newborn Expenses Including Circumcision are covered for the following Children of the covered Employee or covered spouse: natural (biological) Children and newborn Children who are adopted or Placed for Adoption at the time of birth.
41. Nutritional Counseling if Medically Necessary.
42. Nutritional Supplements, Vitamins and Electrolytes which are prescribed by a Physician and administered through enteral feedings, provided they are the sole source of nutrition. This includes supplies related to enteral feedings (for example, feeding tubes, pumps, and other materials used to administer enteral feedings) provided the feedings are prescribed by a Physician, and are the sole source of nutrition due to the following circumstances:
Dietary products used for the treatment of inborn errors of amino acid or urea cycle metabolism are covered when used under the direction of a Physician.
Total parenteral nutrition (TPN) for both Inpatient and outpatient treatment.
43. Occupational Therapy. (See Therapy Services below) 44. Oral Surgery includes:
Excision of partially or completely impacted teeth.
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth when such conditions require pathological examinations.
Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth.
Reduction of fractures and dislocations of the jaw.
External incision and drainage of cellulitis.
Incision of accessory sinuses, salivary glands or ducts.
Excision of exostosis of jaws and hard palate.